Usefulness of the third heart sound in predicting an elevated level of B-type natriuretic peptide

Third heart sounds were sought in 100 consecutive outpatients who had B-type natriuretic peptide (BNP) levels measured within 8 hours. Mean BNP levels were significantly higher in those with a third heart sound. The presence of a third heart sound was 41% sensitive and 97% specific for elevated BNP levels.     

血浆氮末端-前体脑钠肽水平预测心脏再同步化治疗的近期临床疗效

目的:探讨血浆氮末端-前体脑钠肽(NT-proBNP)水平对心脏再同步化治疗(CRT)近期临床疗效的预测价值。方法:入选成功施行CRT的心力衰竭(心衰)患者42例,ELISA法测定血浆NT-proBNP水平。随访6个月,记录心功能分级、左室射血分数(LVEF)、左室舒张末期内径(LVEDd)、QRS间期及心血管事件(心衰再入院、恶性心律失常、心脏性猝死)。结果:入选患者中,CRT有反应者34例,无反应者8例,有效率达81%。CRT术前反应组血浆NT-proBNP水平低于无反应组(P<0.05)。CRT术后6个月反应组LVEF、LVEDd、QRS间期与无反应组比较,均差异有统计学意义(均P<0.01)。Logistic回归分析显示术前NT-proBNP能独立预测CRT临床疗效。术前NT-proBNP对CRT近期临床疗效判定的ROC曲线下面积为0.770,灵敏度为87.5%,特异度为55.9%。结论:血浆NT-proBNP水平可作为评价CRT近期临床疗效的指标。     

Brain natriuretic peptide levels and response to cardiac resynchronization therapy in heart failure patients

The authors used brain natriuretic peptide (BNP) as a reliable marker to identify nonresponders to cardiac resynchronization therapy (CRT) in patients with advanced heart failure. The study included 70 patients with left ventricular dysfunction (mean ejection fraction, 21+/-4%) and left bundle branch block (QRS duration, 164+/-25 milliseconds) treated with CRT. The authors reviewed data on New York Heart Association functional class, baseline ejection fraction, sodium, creatinine, QRS duration, and BNP levels 3 months before and after CRT therapy. The authors compared results of 42 patients who survived (973+/-192 days) after CRT implantation (responders) to those of 28 patients (nonresponders) who either expired (n=21) or underwent heart transplantation (n=5) or left ventricular assist device implantation (n=2) after an average of 371+/-220 days. Mean BNP levels after 3 months of CRT decreased in responders from 758+/-611 pg/mL to 479+/-451 pg/mL (P=.044), while in nonresponders there was increase in BNP levels from 1191+/-466 pg/mL to 1611+/-1583; P=.046. A rise in BNP levels was associated with poor response (death or need for transplantation or left ventricular assist device and impaired long-term outcome), which makes it a good predictor to identify such patients.     

Usefulness of B-type natriuretic peptide in emergency medicine

OBJECTIVES: Acute dyspnea is frequent in emergency medicine. The B-type natriuretic peptide is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. Conversely, NT-proBNP has no physiological activity. BNP and NT-proBNP concentration closely correlate to various indicators of heart failure. CURRENT KNOWLEDGE AND KEY POINTS: Numerous studies have demonstrated high usefulness of BNP and NT-proBNP to diagnose heart failure, which is the main cause of acute dyspnea in emergency medicine. The diagnostic accuracy of BNP and NT-proBNP seems similar, and is higher than that of the emergency physician. Bedside dosages are now available, with high sensibility and specificity for the diagnosis of heart failure. For BNP, threshold value is ranging from 100 to 300 pg/ml in patients aged over 65 years; for NT-proBNP the threshold value is 1000 to 2000 pg/ml in elderly patients. Briefly, heart failure is unlikely when BNP is below 100 pg/ml (NT-proBNP<500 pg/ml), and very likely when BNP is higher than 400 pg/ml (or NT-proBNP>2000 pg/ml). FUTURE PROJECTS: Early rapid measurement of BNP could improved the evaluation and treatment of patients with acute dyspnea and reduce the total cost of treatment.     

Usefulness of brain natriuretic peptide to evaluate patients with heart failure treated with cardiac resynchronization

INTRODUCTION AND OBJECTIVES: The aim of the present study was to document the evolution of the blood levels of brain natriuretic peptide (BNP) in patients with heart failure and their correlation with the clinical course after implantation of a biventricular pacemaker. PATIENTS AND METHOD: Twenty-eight patients with heart failure associated to left bundle branch block and left ventricular systolic dysfunction were included in the study. In each patient we performed laboratory tests, chest X-ray, electrocardiogram and echocardiogram, and measured blood levels of BNP. RESULTS: During follow-up (10 [6] months) functional capacity improved, decreasing from 3.3 (0.6) to 2.10 (0.4) (P=.03). The rate of hospitalizations for heart failure decreased from an average of 1.8 (0.7) (6 months before the procedure) to 0.8 (0.3) (6 months after the procedure; P=.04). The basal value of BNP decreased from 193 (98) pg/mL to 52 (14) at the end of the follow-up in the responder group (22 patients) and increased from 564 (380) to 650 (80) pg/mL in the nonresponder group (6 patients). Patients who responded showed significant clinical improvement and decreasing levels of BNP, which reached a plateau an average of 6 months after implantation. Multivariate logistic regression analysis identified lower levels of BNP, idiopathic dilated cardiomyopathy, and functional class as independent predictors of response to therapy. Age, QRS width and left ventricular ejection fraction were not predictors of response. CONCLUSIONS: Brain natriuretic peptide concentrations allowed us to monitor, in an objective manner, the clinical course of patients with biventricular resynchronization therapy.     

Usefulness of B-type natriuretic peptide and cardiac troponin levels to predict in-hospital mortality from ADHERE

B-type natriuretic peptide (BNP) and cardiac troponin (Tn) I or T have been demonstrated to provide prognostic information in patients with acute coronary syndromes. Whether admission BNP and Tn levels provide additive prognostic value in acutely decompensated heart failure (HF) has not been well studied. Hospitalizations for HF from April 2003 to December 2004 entered into ADHERE were analyzed. BNP assessment on admission was performed in 48,629 (63%) of 77,467 hospitalization episodes. Tn assessment was performed in 42,636 (88%) of these episodes. In-hospital mortality was assessed using logistic regression models adjusted for age, gender, blood urea nitrogen, systolic blood pressure, creatinine, sodium, pulse, and dyspnea at rest. Median BNP was 840 pg/ml (interquartile range 430 to 1,730). Tn was increased in 2,370 (5.6%) of 42,636 HF episodes. BNP above the median and increased Tn were associated with significantly increased risk of in-hospital mortality (odds ratios [OR] 2.09 and 2.41 respectively, each p value <0.0001). Mortality was 10.2% in patients with BNP >or=840/Tn increased compared with 2.2% with BNP <840/Tn not increased (OR 5.10, p <0.0001). After covariate adjustment, mortality risk remained significantly increased with BNP >or=840/Tn not increased (adjusted OR 1.56, 95% confidence interval 1.40 to 1.79, p <0.0001), BNP <840/Tn increased (adjusted OR 1.69, 95% confidence interval 1.17 to 2.45, p = 0.006), and BNP >or=840/Tn increased (adjusted OR 3.00, 95% confidence interval 2.47 to 3.66, p <0.0001). Admission BNP and cardiac Tn levels are significant, independent predictors of in-hospital mortality in acutely decompensated HF. Patients with BNP levels >or=840 pg/ml and increased Tn levels are at particularly high risk for mortality. In conclusion, a multimarker strategy for the assessment of patients hospitalized with HF adds incremental prognostic information.     

心电图对心脏再同步化治疗是否应答的预测价值

目的探讨心电图在心脏再同步化治疗(CRT)应答中的预测价值。方法选取接受CRT(D)的患者作为研究对象,术后随访至少6个月,根据临床效果分为应答组与无应答组。分析术前术后患者QRS波时限,术前ST段下移值、QTc间期、有无病理性Q波及QRS波切迹对CRT应答是否有预测价值。结果共入选51例患者,6例失访,剩余45例纳入研究,24例CRT有应答,比例为53.3%,死亡8例。应答组术前心电图存在QRS波切迹明显低于无应答组(5/24 vs 16/21例,P=0.03);应答组术后心电图QRS波时限显著短于无应答组[(137.1±27.9)ms vs(166.3±28.5)ms,P0.05],且对CRT预后有预测价值(OR=0.964,95%CI 0.942~0.998,P=0.004),分界值为125 ms。结论心电图对CRT的应答有一定的预测作用。     

Decrease in plasma B-type natriuretic peptide early after initiation of cardiac resynchronization therapy predicts clinical improvement at 12 months

BACKGROUND: Decrease in neurohormonal activation during pharmacotherapy for chronic heart failure (CHF) is associated with haemodynamic and clinical improvement. We tested the hypothesis that changes in neurohormonal activation after initiation of cardiac resynchronization therapy (CRT) predict its long-term clinical effect. METHODS: The study group included 43 patients with CHF (37 males, mean age 62+/-9 years, NYHA class 3.2+/-0.4, QRS duration 195+/-24 ms) who underwent successful implantation of a CRT system. Pharmacotherapy remained stable during the first 3 months of follow-up. Plasma levels of B-type natriuretic peptide (BNP) and big endothelin-1 (big ET-1) were evaluated before and 3 months after implantation. Clinical, echocardiographic and exercise parameters were monitored for a mean period of 25.8+/-6.7 months. RESULTS: At 12 months of follow-up 13 non-responders were identified (no improvement in NYHA class (n=10), urgent heart transplantation (n=2) and death due to progressive heart failure (n=1)). CRT resulted in a significant reduction in neurohormone levels (BNP 345.4+/-346 vs. 267.7+/-320.8 pg/ml, p<0.01, big ET-1 3.11+/-1.50 vs. 2.50+/-1.56 fmol/ml p<0.05), especially in responders. Percentage change in BNP level was a stronger predictor of long-term clinical improvement than clinical, echocardiographic and exercise parameters at 3 months of follow-up. CONCLUSIONS: Percentage change in plasma BNP levels from baseline to 3 months was the strongest predictor of long-term response to CRT and may have potential to predict outcome.     

QRS波时限预测心脏再同步治疗反应价值的研究进展

目前心脏再同步治疗(CRT)患者主要是根据体表心电图QRS波时限来判断是否存在心脏的不同步.但是临床上心脏的机械收缩不同步与电不同步之间并非完全相关.少数QRS波时限明显增宽患者,并不存在机械收缩的不同步,而部分QRS波时限不增宽的患者,却存在机械收缩的不同步.明确心脏是否存在机械不同步,或许能减少CRT无应答.本文关于QRS波时限预测心脏再同步治疗存在的价值进行综述,进一步探讨QRS波时限对CRT治疗的影响.     

Usefulness of triplane tissue Doppler imaging to predict acute response to cardiac resynchronization therapy

This study evaluated the value of triplane tissue Doppler imaging (TDI) to predict acute response after cardiac resynchronization therapy (CRT). Forty-nine patients scheduled for CRT underwent triplane echocardiography with simultaneous TDI acquisition before and 48 hours after implantation. A 3-dimensional left ventricular (LV) volume was generated and LV volumes and ejection fraction were calculated. A parametric imaging technique, tissue synchronization imaging, was applied to portray the area of latest mechanical activation. LV dyssynchrony was quantitatively analyzed by evaluating time from QRS onset to peak myocardial velocity in 12 LV segments from the triplane dataset. Acute response was defined as > or =15% decrease in LV end-systolic volume. Receiver-operating characteristic curves of dyssynchrony parameters were analyzed to identify predictors of response to CRT. Acute response was observed in 47% of patients. Responders had a significantly larger extent of LV dyssynchrony at baseline compared with nonresponders. Optimal prediction of acute response to CRT was obtained with the SD of time delays in all LV segments (sensitivity 91%, specificity 85%). In conclusion, 3-dimensional TDI echocardiography permits parametric and quantitative analyses of LV dyssynchrony and assessment of LV volumes and ejection fraction. LV dyssynchrony parameters, derived from the triplane TDI dataset, were highly predictive for acute volumetric response to CRT.     

Usefulness of echocardiographic tissue synchronization imaging to predict acute response to cardiac resynchronization therapy

Echocardiographic tissue synchronization imaging (TSI) consists of color-coding time-to-peak tissue Doppler velocities. This study of 29 patients who underwent cardiac resynchronization therapy (CRT) demonstrated that differences in baseline time-to-speak velocities of opposing ventricular walls by TSI were greater in 15 patients, with an acute hemodynamic improvement. A >/=65 ms delay from the anterior septum to the posterior wall using the apical long-axis view had 87% sensitivity and 100% specificity for predicting an acute response. Although a subgroup without acute improvement had later decreases in end-systolic volume, suggesting that acute response underestimates long-term effects, TSI has potential to assist in guiding CRT.     

Usefulness of tissue Doppler velocity and strain dyssynchrony for predicting left ventricular reverse remodeling response after cardiac resynchronization therapy

The assessment of systolic dyssynchrony by echocardiography is useful in predicting a favorable response to cardiac resynchronization therapy (CRT). Tissue Doppler velocity and tissue Doppler longitudinal strain have been suggested for this purpose. This study compared parameters of systolic dyssynchrony derived from these 2 imaging modalities for their predictive values of CRT response. Two hundred fifty-six patients from 3 different centers who received CRT were followed for 6 +/- 3 months. Parameters of systolic dyssynchrony based on tissue Doppler velocity and strain imaging were assessed for the prediction of left ventricular (LV) reverse remodeling (reduction of LV end-systolic volume > or =15%). These included time to peak systolic velocity (or peak strain) of 12 LV segments to calculate the SD (Ts-SD or Tepsilon-SD), maximal difference in delay (Ts-Diff or Tepsilon-Diff), and opposite wall delay (Ts-OW or Tepsilon-OW). The septal-to-lateral delay (Ts-Sep-Lat or Tepsilon-Sep-Lat) was also measured. LV reverse remodeling, defined as improvement in end-systolic volume > or =15%, was observed in 141 patients (55%). All 4 tissue velocity parameters predicted LV reverse remodeling, and the areas under the receiver-operating characteristic curves were 0.86, 0.85, 0.84, and 0.79 for Ts-SD, Ts-Diff, Ts-OW, and Ts-Sep-Lat, respectively (all p <0.001). The cut-off values derived from receiver-operating characteristic curve analysis were 33 ms for Ts-SD, 100 ms for Ts-Diff, 90 ms for Ts-OW, and 60 ms for Ts-Sep-Lat, and their sensitivities were 93%, 92%, 81%, and 70%, with specificities of 78%, 68%, 80%, and 76%, respectively. In contrast, none of the longitudinal strain parameters predicted LV reverse remodeling. The areas under the receiver-operating characteristic curves ranged from 0.49 to 0.53 (all p = NS). The same conclusions were obtained in subgroup analyses of QRS duration (120 to 150 vs >150 ms) and ischemic or nonischemic cause of heart failure. In conclusion, parameters of tissue Doppler longitudinal velocity, but not longitudinal strain, predicted LV reverse remodeling after CRT.     

Utility of three-dimensional echocardiography in assessing and predicting response to cardiac resynchronization therapy

BACKGROUND

Cardiac resynchronization therapy (CRT) can be a valuable treatment for heart failure. However, there are high nonresponse rates using current CRT inclusion criteria.

OBJECTIVE

To assess the value of three-dimensional echocardiography (3DE) in predicting response to CRT.

METHODS

Functional assessments and 3DE were performed in heart failure patients pre-CRT, 24 h post-CRT and six to 12 months after CRT. The dyssynchrony index (DI) was calculated as the SD of the time to minimum volume in 16 left ventricle segments corrected by heart rate. Response to CRT was defined as functional improvement (alive at late follow-up with improvement by one New York Heart Association class) and a decrease in left ventricular end-systolic volume by 15% or greater at six to 12 months follow-up.

RESULTS

A total of 53 patients were enrolled. Average 3DE acquisition time was less than 5 min. Seventy-two per cent of patients showed functional improvement, while 43% showed functional and echocardiographic evidence of response. Baseline DI and the decrease in DI at 24 h were both correlated with reverse remodelling. Responders had higher baseline DI values compared with nonresponders (mean 16.8 versus 7.1, P<0.001), and showed a greater decrease in DI values at 24 h (mean decrease 7.9 versus 0.7, P<0.001). All responders had baseline DI values of greater than 10 (negative predictive value of 100%). A decrease in the DI value by more than 5 at 24 h in patients with a baseline DI of greater than 10 identified responders with a positive predictive value of 83%.

CONCLUSIONS

3DE may be valuable in predicting response to CRT. A baseline DI cut-off of greater than 10 in our patients excluded reverse remodelling to CRT. In addition, the decrease in DI at 24 h had a high positive predictive value for long-term response to CRT.     

Usefulness of plasma B-type natriuretic peptide in predicting recurrence of atrial fibrillation one year after external cardioversion

After successful external cardioversion, the rate of recurrence of atrial fibrillation remains high. The hypothesis that plasma B-type natriuretic peptide could predict the recurrence of atrial fibrillation at 1 year was tested. Plasma B-type natriuretic peptide was measured in 66 consecutive asymptomatic patients who underwent external cardioversion for atrial fibrillation. Twelve-lead electrocardiograms were obtained at 1 year. Sinus rhythm was maintained in 55% of patients. The independent predictors of the recurrence of atrial fibrillation at 1 year were a history of atrial fibrillation, plasma B-type natriuretic peptide, and the energy delivered for conversion. In patients without symptoms of heart failure, plasma B-type natriuretic peptide is an independent predictor of the recurrence of atrial fibrillation.     

Usefulness of an elevated B-type natriuretic peptide in predicting survival in patients with aortic stenosis treated without surgery

Patients with aortic stenosis (AS) may remain asymptomatic with good prognoses for many years but have poor prognoses once they develop symptoms. Because the presence of symptoms is subjective, B-type natriuretic peptide (BNP) may provide a more objective indication of the prognoses of patients with AS. We evaluated 124 patients with AS (valve area <1.2 cm(2)) with clinical evaluation, Doppler echocardiography, and BNP assessment and obtained up to 2 years of follow-up without valve replacement. Patients with syncope, angina, and/or heart failure were considered to have symptoms. The 24 patients without symptoms had lower BNP levels (187 +/- 193 pg/ml) than the 100 patients with symptoms (930 +/- 928 pg/ml, p <0.001). BNP indicated symptom status, with an area under the receiver-operating characteristic curve of 0.87 (p <0.001). The optimal discrimination of symptoms occurred with BNP >190 pg/ml. Survival was significantly influenced by the presence of symptoms (relative risk [RR] 7.5, p <0.01) and BNP tertile (RR 2.9, p <0.001). The 1-year mortality rate without surgery was 6% for BNP <296 pg/ml, 34% for BNP 296 to 819 pg/ml, and 60% for BNP >819 pg/ml. No patients with BNP <100 pg/ml died. The combination of BNP and symptoms provided a better prediction of survival than symptoms alone (chi-square 13.6, p <0.001). BNP significantly (RR 2.8, p <0.01) influenced survival after correction for other univariate predictors (coronary artery disease, symptoms, functional class, ejection fraction, and aortic valve area). In conclusion, elevated BNP indicates progressively worse survival in patients with AS treated medically. Thus, the measurement of BNP supplements the evaluation of symptoms in determining the prognoses of patients with AS.     

Value of peri-procedural B-type natriuretic peptide levels in predicting cardiac events after elective percutaneous coronary intervention

OBJECTIVE: B-type natriuretic peptide (BNP) has diagnostic and prognostic value in a wide variety of cardiac disorders including heart failure and acute coronary syndromes. We aimed to evaluate the prognostic value of baseline and post-procedural BNP levels in predicting major adverse cardiac events (MACE) in stable coronary artery disease (CAD) patients undergoing elective percutaneous coronary intervention (PCI). METHODS: Blood samples for BNP were obtained before, 1 hour and 24 hours after PCI of stable CAD patients who underwent elective PCI for de novo lesions in native coronary arteries. Patients were followed for 12 months for the occurrence of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, hospitalization with angina or repeat revascularization. RESULTS: Among the 95 patients with one-year follow-up data 22 had MACE. Baseline clinical and procedural characteristics of patients with and without MACE were similar. Only EF was significantly lower (P < 0.001) and complex lesion type was significantly more common in patients with MACE (P = 0.012). All measured plasma BNP levels were significantly higher in patients with MACE compared to those free of MACE (baseline P < 0.001, 1st hour P = 0.001 and 24th hour P < 0.001). Multiple logistic regression analysis identified the EF (P = 0.026) and 24th hour BNP (P = 0.002) as independent predictors of MACE. If baseline or post-PCI 1st hour BNP levels were put into analysis instead of post-PCI 24th hour BNP the predictive value of BNP lost its significance (both P > 0.05). CONCLUSION: Post-PCI 24th hour BNP is an independent predictor of MACE during 12 months of follow-up after elective successful PCI.     

Usefulness of B-type natriuretic peptide as a noninvasive screening tool for cardiac allograft pathology in pediatric heart transplant recipients

We examined the utility of B-type natriuretic peptide (BNP) in the evaluation of pediatric orthotopic heart transplant recipients for allograft pathology by measuring the serum BNP levels at the time of either screening echocardiography and biopsy, or at the time of clinical rejection. There was a significant difference (p <0.0001) in the BNP levels in 37 patients in the group with evidence of pathology compared with those without evidence. There was also 100% sensitivity and 100% negative predictive value of BNP levels >100 pg/ml for identifying graft pathology.